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Cardiothoracic & Vascular Surgical Associates, P.A. PATIENT INFORMATION Social Security Number: Last: Sex: M F D.O.B. MI: First: Suffix: City: Address: State: Zip: Home Phone: Work Phone: Ext: Cell

How to fill out new-patient-paperwork-01112016--for-website1pdf

How to fill out new-patient-paperwork-01112016--for-website1pdf:

1. Start by opening the document on your computer or device.
2. Read through the instructions provided at the beginning of the paperwork to familiarize yourself with the requirements.
3. Begin by entering your full name in the designated field. Make sure to provide your first name, middle initial (if applicable), and last name accurately.
4. Date the form by filling in the current date in the specified format (e.g., MM/DD/YYYY).
5. Enter your date of birth in the appropriate section. Again, use the specified format (e.g., MM/DD/YYYY).
6. Provide your gender by selecting the corresponding option (e.g., male, female, other).
7. Indicate your marital status by selecting the appropriate choice (e.g., single, married, divorced).
8. Enter your complete home address, including street, city, state, and zip code.
9. Provide your primary phone number and, if applicable, secondary phone number.
10. Fill in your email address, ensuring it is accurate as this may be used for communication purposes.
11. If you have an emergency contact person, provide their name, phone number, and their relationship to you.
12. Provide the name and contact information of your primary care physician or any referring physician if applicable.
13. If you have health insurance, provide the necessary details, including the insurance company's name, policy number, and group number.
14. Next, you may need to provide information about any current medications you are taking. List the name of the medication, the prescribed dosage, and the frequency at which you take it.
15. If you have any allergies or adverse reactions to medications, be sure to specify them in the appropriate section.
16. Answer any other medical history questions as instructed, such as previous surgeries, chronic conditions, or family medical history.
17. Carefully review the form to ensure all the provided information is accurate and complete.
18. Once you're satisfied, you may need to print and sign the document. Follow the instructions given on how to submit the paperwork, whether it is to be brought to your first appointment or submitted electronically.

Who needs new-patient-paperwork-01112016--for-website1pdf:

1. Individuals who are seeking medical care at a specific facility or clinic.
2. Patients who are new to a healthcare provider and need to establish their medical records.
3. Anyone who has scheduled an appointment with a healthcare professional and is required to complete new patient paperwork prior to the visit.

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What is new-patient-paperwork-01112016--for-website1pdf?

It is a form for new patients to fill out for website1 on 01/11/2016.

Who is required to file new-patient-paperwork-01112016--for-website1pdf?

All new patients visiting website1.

How to fill out new-patient-paperwork-01112016--for-website1pdf?

Fill out the form with accurate information about your medical history and contact details.

What is the purpose of new-patient-paperwork-01112016--for-website1pdf?

The purpose is to gather necessary information about new patients for website1.

What information must be reported on new-patient-paperwork-01112016--for-website1pdf?

Medical history, contact details, insurance information, etc.